Auburn Post Acute

Inspectors wroteBased on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 4 (Q4, October 2025, November 2025, December 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the kitchen environment was sanitary and the meal service followed the requirements in accordance with professional standards of food safety for 1 of 1 facility kitchen observed. The failure to ensure: (1) the kitchen ceiling was kept clean and intact; (2) cabinets had working doors and drawers; (3) garbage/trash receptacle had a lid or was covered; and (4) proper food handling practice was observed to avoid cross-contamination placed residents at risk for ingesting unsafe and/or contaminated food and the development of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure and designate a qualified staff person to serve as an Infection Preventionist (IP). This failure placed residents at risk for unmet infection control issues and prevented a lack of overside of the facility staff's infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all portions of the communication system were functioning and adequately equipped to allow residents to call for staff assistance to a centralized staff work area from each resident's bedside for 2 of 2 nursing units (North Unit and South Unit) and from toileting areas for 2 of 2 first floor bathrooms (Bathrooms 1 & 2) reviewed for call light system. The facility failed to ensure staff responded timely to residents' call lights and the pull cord at each bathroom was accessible to a resident lying on the floor in case of an emergency. These failures placed residents at risk for delayed care, pain or discomfort, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided a safe, homelike environment for 2 of 2 units (North Unit and South Unit) and safe accessible use of 2 of 2 bathrooms (first floor public bathrooms 1 & 2). The failure to ensure resident rooms were free of wall scrapes, floor thresholds, broken window blinds, unpleasant stains, and safe accessible bathrooms placed residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow the required discharge process for 3 of 6 residents (Residents 84, 55, & 8) reviewed for hospitalizations. The failure to inform residents of the facility's bed hold (a process by which a resident can pay a daily rate to ensure they can return to the same bed when they readmit) policy placed residents at risk for losing their right to return to their bad and frustration.

Inspectors wroteBased on interview and record review, the facility failed to complete resident assessments within the regulatory timeframes for 10 of 14 residents (Residents 15, 84, 18, 11, 2, 35, 38, 44, 55, & 6) reviewed for comprehensive assessments and timing. The failure to ensure comprehensive admission and Annual Minimum Data Set (MDS - an assessment tool) assessments were completed timely delayed the residents' care planning process necessary to provide the appropriate care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure Care Plans (CPs) were developed and implemented as required for 5 of 19 sample residents (Residents 35, 55, 15, 9, & 48) whose CPs were reviewed. The failure to ensure CPs were comprehensive, resident-specific, and implemented placed residents at risk for unmet care needs, inappropriate care, and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 3 of 5 residents (Residents 9, 15, &1) reviewed for ADLs. The failure to provide dressing assistance (Resident 9) and personal hygiene/grooming needs (Residents 15 & 1) left residents at risk for body odors, unmet care needs, diminished feeling of self-worth, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure the main entrance to the facility was safely accessible to all residents for 1 of 1 main entrances, failed to ensure sharps containers were emptied before becoming a hazard for 3 of 4 nurse carts, and failed to provide sufficient fall management for 2 of 4 (Residents 24 & 40) residents reviewed for falls. These failures placed residents at risk for injury, blood borne pathogen exposure, avoidable falls, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure urinary catheters were maintained according to professional standards of nursing (tubing used to facilitate bladder drainage) for 2 of 3 residents (Residents 35 & 15) reviewed for urinary catheter. The failure to ensure catheter bags were placed correctly and emptied as needed placed residents at risk for infection, discomfort, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure narcotic logs were maintained in a manner which preserved original documentation and accurate controlled substance accounting for 1 resident (Resident 18), ensure expired medications were discarded timely and refrigerator temperatures were logged for 1 of 1 medication storage rooms (Medicare Medication Room) and 2 of 4 medication carts (Long term care south medication cart and Medicare south medication cart) reviewed for medication storage, and failed to ensure the treatment cart was secured for 1 of 1 treatment carts. This failure placed residents at risk of receiving incorrect or expired medications, ineffective treatment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 3 residents (Residents 31, 32, & 5) and 1 family member were educated and provided the facility policy regarding the use and storage of foods brought by family and visitors in the facility from outside sources including safe food handling practices. This failure placed residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to adhere to Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms) for 3 of 10 residents (Resident 46, 78, & 1) reviewed for infection control, failed to ensure resident equipment was able to be hygienically cleaned for Resident 8, and failed to ensure the facility's washing machine was maintained at the proper temperature. These failures placed residents at risk for communicable diseases, poor quality of life, and adverse health outcomes.

Inspectors wroteBased on interview and record review the facility failed to establish an infection prevention and control program that included implementation of the Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 1 of 5 residents (Resident 1) reviewed for unnecessary medications. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABOs.

Inspectors wroteBased on interview and record review, the facility failed to provide informed consent and risks and benefits of treatment for 3 of 5 residents (Residents 1, 84, & 40) reviewed for unnecessary medications. This failure placed residents at risk for unwanted treatments, diminished quality of life, and adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to initiate, log, and complete thorough grievance investigations for 1 of 5 residents (Residents 18) and 1 supplemental resident (Resident 39) who were reviewed for grievances. This failure to ensure thorough investigations and resolutions placed residents at risk for frustration and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status for 3 of 19 sample residents (Residents 1, 4, & 18) reviewed for accuracy of assessments. This failure placed residents at risk for unmet and/or unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessment was accurate to reflect the residents' mental health conditions for 1 of 7 residents (Residents 18) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on interview and record review the facility failed to provide routine care conferences for 2 of 3 residents (Resident 7 & 40) sampled for care planning. This failure placed residents at risk for unmet care needs, frustration, and diminished quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services according to professional standards of quality and accepted standards of clinical practice for 7 of 19 residents (Residents 9, 72, 40, 1, 4, 7, & 8) whose medical records were reviewed for physician orders, medication administration, assessments, monitoring, and documentation. The facility failed to ensure residents' weight (loss or gain) was identified, monitored, and documented (Residents 9 & 72), pain and blood pressure medications were administered with and/or according to established parameters ( Residents 40 & 1), skin evaluations were completed (Resident 4), respiratory care was followed as ordered (Residents 7 & 1), bowel care was followed as ordered (Resident 1), and physician orders were discontinued after completion (Resident 8). [...]

Inspectors wroteBased on interview and record review the facility failed to provide Restorative Nursing Programs (RNP) for 1 of 1 residents (Resident 7) reviewed for restorative services. The failure to provide restorative services placed residents at risk for decline in mobility and Range of Motion (ROM), functional status, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for 1 of 1 residents (Resident 4) that required enteral feeding (Tube Feeding - food delivered to the stomach via tubing that bypasses the esophagus) received the nutrition they required in accordance with professional standards of nursing. The failure to ensure tube feeding was provided in accordance with the physician's orders, and accurately documented with the nutrition provided, placed residents at risk for unwanted weight loss, unwanted weight gain, gastrointestinal discomfort, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide special/adaptive eating equipment and utensils to residents who needed them for 1 of 1 resident (Resident 70) observed during dining. This failure placed residents at risk of losing their ability to eat independently, feelings of frustration, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident to resident altercations including alleged sexual, physical, and verbal abuse incidents the facility was aware of or witnessed was investigated, logged, and reported for 8 of 10 residents (Resident 9, 11, 16, 17, 6, 7, 4, 5) reviewed for abuse. The failure to investigate these incidents deterred the facility from preventing re-occurrence and taking appropriate corrective actions resulting in repeated abuse that placed all residents at risk for unidentified abuse and/or continued abuse, psychological harm, and diminished quality of life, and constituted an Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to timely and accurately assess resident's ability to smoke safely; implement a resident specific care plan for smoking; secure smoking supplies; ensure a safe designated smoking area; and implement, and enforce the facility smoking policy for 7 of 9 residents (Residents 13, 8, 12, 14, 15, 18, & 19) reviewed for smoking. In addition, the facility failed to re-assess Resident 16's ability to smoke independently after a cigarette burn, and failed to provide supervision to 1 of 3 residents (Resident 8) who was assessed to require supervision outside of the facility, used a Wander Guard device (a device that sets off an alarm to notify staff if the resident is close to the exit door) and eloped from the facility five times. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 3 of 3 residents (Resident 1, 2, & 3) reviewed for Pressure Ulcers (PU-injury to the skin and underlying tissue due to prolonged pressure) received the necessary care and services, consistent with professional standards of practice to prevent new PU's from developing. Failure to implement wound prevention interventions, assess PU risk, complete and document skin and wound assessments, ensure treatments were carried out as ordered, to notify the facility dietician of new PU's, and to ensure skin was assessed thoroughly during skin assessments and during care activities. Resident 1 experienced harm when they developed avoidable full thickness (wounds that extend beyond the first two layers of skin into the fat and muscle tissue) PU's on each elbow. [...]

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to efficiently and effectively manage the facility in compliance with state and federal regulatory requirements to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The failure to ensure oversight, monitoring, investigation, reporting, and implement prevention to ensure resident safety for incidents of abuse, smoking and elopement, and ensure mandatory staff training and competency, placed all residents at risk for physical, sexual and verbal abuse, resident altercations, physical, mental and psychological harm, serious injuries, unmet needs, and dissatisfaction with their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and effectively maintain a smoking policy in accordance with applicable Federal, State, and local laws and regulations regarding smoking, smoking areas, and smoking safety for resident smokers, resident non-smokers, and staff. The failure to monitor and intervene when the smoking policy was not followed, failure to provide a safe designated smoking area, and failure to ensure resident safety while smoking, placed residents at risk for serious adverse outcomes including potential for fire, explosion, and/or serious injuries.

Inspectors wroteBased on interview and record review the facility failed to develop, implement and permanently maintain an in-service training program for nurse aides that was appropriate and effective, as determined by nurse aide performance reviews and the facility assessment for 3 of 3 nurse aide staff (Staff X, Y, & Z) reviewed for training and competency. The failure to have a system to provide a minimum of 12 hours of nurse aide training per year, conduct nurse aide performance reviews to address weaknesses for additional training, track nurse aide participation in required training with documentation of completed in-service education, and assess nurse aide demonstration of competency to meet residents' needs, placed all residents at risk for unmet needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 1 of 2 residents (Resident 10) reviewed for resident-to-resident incidents. The failure to protect Resident 10 who experienced unwanted and unconsented inappropriate touching of their breasts by another resident placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 2 (Q2, April 2025, May 2025 and June 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision to 1 (Resident 1) of 3 residents reviewed for elopement and accidents. The facility failed to provide supervision to Resident 1. These failures placed Resident 1 at a potential risk of harm, injury, and avoidable accidents. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; there was sufficient evidence the facility corrected the supervision failures after it was identified) and is no longer outstanding.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain intact resident room doorways, keep resident walls free of chipping paint, scuffs, and stains, keep hallways free of clutter, and ensure resident rooms were personalized for 3 of 4 units (Long Term 1, Short Term 1, & Short Term 2) left residents at risk for a less-than homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable, and ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 5 (Residents 36, 120, 25, 19, & 52) of 5 residents reviewed for hospitalizations. The failure to ensure written notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges. [...]

Inspectors wrote<Resident 120> According to the 12/24/2024 admission MDS, Resident 120 had a moderate memory impairment, and medically complex diagnoses, including a multiple infections. According to a 01/05/2025 nursing progress note Resident 120 was observed to be congested with thick mucus and unable to expectorate. The note showed the doctor was called and the resident was transferred to the hospital. Record review showed no proof Resident 120 was offered a bed hold to ensure they were informed of the opportunity to return to their current room and understood how much that would cost. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received and/or participated in care conferences for 6 (Residents 50, 57, 23, 25, 49, & 38) of 20 residents reviewed and failed to ensure Care Plans (CP) were updated and/or revised to reflect person-centered care for 1 (Residents 36) of 22 sample residents whose CPs were reviewed. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident meals were prepared following the menu as directed for 1 of 1 meal preparations observed. The failure to prepare meals according to the dietician approved spreadsheet placed residents at risk of unmet nutritional needs, and other potential negative health/nutritional outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were maintained comprehensively and readily accessible for 8 of 20 sample residents whose records were reviewed (Residents 1, 4, 120, 44, 33, 25, 49, & 23). The failure to ensure health records were added to the chart timely placed residents at risk for incomplete medical records, delays in treatment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff performed Hand Hygiene (HH) in accordance with standard precautions and/or remove Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 1 supplemental resident (Residents 269), maintain clean resident equipment, cleanable surfaces throughout the facility, and establish a water management program that assessed and monitored measures to prevent the growth of Legionella (bacteria that could cause a serious lung infection), and other opportunistic waterborne pathogens in the facility's water systems. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment.

Inspectors wrote<Standing While Feeding> <Resident 4> According to an 11/26/2024 Significant Change MDS, Resident 4 had a functional limitation in range of motion to one side of their upper arms and required substantial assistance from staff for eating. Review of Resident 4's Self-Care care plan showed the resident required one person assistance with eating their meals. Observations on 01/28/2025 at 12:40 PM showed Staff C (Resident Care Manager) standing next to Resident 4 in the dining area. Staff C was assisting Resident 4 with their fluids during lunch by holding the cup while the resident would drink in between taking bites of food. Staff C continued to stand at Resident 4's side assisting with fluids until 1:05 PM, 25 minutes later, at which time Staff C grabbed a nearby chair. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits was provided) for the use of a device for 1 (Resident 48) of 4 residents reviewed for positioning and failed to provide informed consent regarding high-risk medications for 3 (Residents 64, 44, & 33) of 5 sample residents and 1 (Resident 419) supplemental resident. These failures placed residents at risk for loss of autonomy and the opportunity for alternative treatment options.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective program to ensure resident Advanced Directives (ADs - legal documents describing treatment wishes for when a resident is incapacitated) were included in the record and residents without ADs were offered assistance to formulate one for 2 (Residents 120 & 49) of 6 residents reviewed for ADs. This failure placed residents at risk for not having their treatment goals met and other negative health impacts.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate an injury accident for 1 (Resident 6) of 8 residents reviewed for accidents, rule out abuse for 1 (Resident 38) of 3 sampled residents reviewed for abuse and investigate a fall for 1 (Resident 419) of 2 reviewed for falls. Facility failure to complete thorough investigations placed residents at risk for further injuries, potential abuse, and other negative health outcomes.

Inspectors wrote<Resident 25> According to a 08/29/2024 Annual MDS Resident 25 admitted [DATE]. The MDS showed Resident 25 had their natural teeth without any issues. Review of a 06/27/2024 Activities of Daily Living CP, Resident 25 had no natural teeth and had an upper denture but no lower denture. The CP showed Resident 25 required staff assistance with cleaning the denture and the residents' mouth/gums twice daily. In an interview on 01/31/2025 at 9:27 AM Staff P stated Resident 25's MDS showed they had their natural teeth without issues. Staff P stated the MDS should show that the resident has the upper denture and no natural teeth. Staff P stated it was important for the MDS to be accurate to plan residents care appropriately. REFERENCE: WAC 388-97-1000 (1)(b). [...]

Inspectors wrote<Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 admitted to the facility on [DATE], had multiple medically complex diagnoses including anxiety, depression, and schizophrenia (a serious mental health condition that affects how people think, feel, and behave), and required the use of an antidepressant and antipsychotic medication during the assessment period. Review of the January 2025 medication administration records showed Resident 44 was receiving an antidepressant and antipsychotic medications daily. Review of a 07/03/2024 Level 1 PASRR showed Resident 44 had no serious mental illness indicators identified, and a Level II evaluation was not indicated. In an interview on 01/30/2025 at 1:54 PM, Staff E stated upon admission the Level 1 PASRR should be assessed by staff for accuracy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were clarified for 4(Residents 38, 64, 44 & 33) of 20 sample residents reviewed and physician parameters were followed for 2 of 5 residents (Resident 44, & 49) reviewed for unnecessary medications with 1 supplemental resident (Resident 50) reviewed. These failures placed residents at risk for ineffective treatments, medications errors, and delayed treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nailcare and assistance with shaving facial hair for residents dependent on staff for Activities of Daily Living (ADLs - grooming, oral hygiene, nail care etc.) for 3 of 6 (Residents 120, 36, & 21) residents and 1 supplemental resident (Resident 169) reviewed for ADLs. This failure placed residents at risk for poor hygiene, skin impairment, and a diminished sense of self-worth.

Inspectors wrote<Resident 36> According to a 11/28/2024 Quarterly MDS, Resident 36 had clear speech, was able to understand and be understood by others, and had no memory impairment. This MDS showed staff assessed Resident 36 to be at risk of developing pressure ulcers and had no ulcers, wounds, or skin problems. In an interview on 01/28/2025 at 8:36 AM, Resident 36 stated they had a rash on their abdomen and thighs which developed after they received a recent vaccination. Resident 36 stated the doctor ordered some medications that were helping to decrease the itching. Review of Resident 36's records showed the resident received a vaccination on 01/16/2025. Review of a 01/23/2025 communication form to the provider showed staff documented Resident 36 complained of increased itching which started on 01/16/2025 and had, some kind of dermatitis [swelling, redness, and itching]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assessed for the need, ability, and safety of devices, and movement in bed for 2 of 5 residents (Residents 25 & 49) reviewed for accident hazards, and 1 supplemental resident (Resident 6). The failure to reassess use of a power wheelchair when required placed residents at risk for power wheelchair accidents. The failure to complete safety assessments for beds against the wall placed Residents 25 & 49 at risk of entrapment and injury.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 (Residents 120 & 38) of 5 sampled residents reviewed for nutrition received adequate weight monitoring. The failure to ensure a reweigh occurred after a significant weight change placed residents at risk for weight changes, and inaccurate assessment of nutritional status. <Facility Policies> According to the facility's 2023 Nutritional Management policy, the facility provided care and services to ensure resident maintained acceptable parameters of nutritional status . The facility's 2022 Weight Monitoring policy showed weight was a useful indicator of nutritional status and significant weight loss could indicate a nutritional problem. The policy showed a weight loss of greater than five percent (%) in one month represented a significant weight loss. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach) was administered in accordance with physician orders and professional standards of practice for 1 of 1 sampled resident (Resident 23) reviewed for enteral nutrition. The facility failed to accurately document the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive and deliver per physician orders. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 2 of 25 medications for 2 of 6 residents (Resident 10 & 419) observed during medication pass resulted in a medication error rate of 8 %. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident 1) reviewed for sexual abuse. Resident 1 experienced psychological harm, applying the reasonable person approach (how a reasonable person would respond under the same circumstances), when they were inappropriately touched on their breast by Resident 2. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) to include teeth brushing, transfers out of bed, and assistance with eating for 1 of 3 dependent residents (Residents 1) reviewed for ADL's. The failure to provide assistance with teeth brushing, transfers out of bed and eating to dependent residents, placed residents at risk for decreased intake, weight loss, poor hygiene, skin breakdown, embarrassment, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure Physician Orders (PO) were reviewed, clarified and implemented upon admission and after a physician visit, and failed to document on new pressure ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure on the skin). These failures caused Resident 1 to experience skin breakdown, and placed all residents at risk for skin breakdown, pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide consistent supervision and ensure a safe environment that was free from dangerous accident hazards for 6 of 14 residents (Resident 1, 4, 8, 3, 9 & 5) reviewed for smoking. The failure to: timely and accurately assess resident's ability to safely smoke; secure smoking paraphernalia; implement, and enforce the facility smoking policy when Resident 1 was found smoking in the facility and a common area repeatedly, including near a resident who required and was wearing oxygen, placed all residents at risk for serious adverse outcomes with the potential for fire and an explosion and/or serious bodily injury, and constituted an Immediate Jeopardy (IJ). On 04/18/2024 an IJ was identified in F-689 and the provider was informed. The IJ was determined to begin on 04/13/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure direct care staff were provided the mandatory effective communication training. Failure to ensure the required effective communication training was provide placed all residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided a comfortable homelike environment for 3 of 5 residents (Resident 1,12, 6) reviewed. The failure to ensure the facility boiler was repaired timely and water temperatures were maintained at comfortable levels, placed all residents at risk for decreased cleanliness, quality of life, dignity, and a homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs-bathing, grooming, eating) received the assistance they required for 6 of 6 residents (Residents 12, 14, 9, 1, 3, & 10 ) reviewed for bathing and showers. The failure to provide bathing or showers placed all residents at risk for poor hygiene, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent placing residents at risk for facility acquired infections. The failure to have an effective system of surveillance to identify possible contagious infections, prevent the spread of infection to there residents and staff, reporting a suspected outbreak, and controlling the spread of a Gastrointestinal (GI) infection to other residents for 3 of 3 residents (Residents 15, 18, & 19 ) reviewed for infections. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 2 residents (Residents 16 & 15) reviewed for resident-to-resident incidents. This failed practice resulted in psychological harm, applying the reasonable person approach (a reasonable person in this situation would be upset, angry, and feel violated), for Resident 16 who experienced inappropriate sexual touching by Resident 14, and for Resident 15 who was inappropriately slapped by Resident 14. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their abuse and neglect policies and procedures regarding prevention, identification, investigation, and reporting of abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for 3 of 3 residents (Resident 1, 2 & 3) reviewed for accidents. The facility failed to provide supervision to Resident 1, who resided on the second floor with a wander guard in place, when they eloped from the first floor of the facility unnoticed, and experienced harm when they fell from their wheelchair and sustained a head injury, an abrasion to the head, and required an evaluation at a local hospital. The facility failed to implement fall prevention measures after Resident 1 experienced harm from a fall and after that fall , experienced a suspected fall that caused a leg fracture and a laceration to their forehead that required suture repair. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received wound care consistent with professional standards of practice that prevented skin breakdown and the development and/or worsening of Pressure Ulcers (PUs) for 5 of 6 (Residents 55, 65, 32, 53 & 24) residents reviewed for treatment and services for PUs. Three residents (Residents 55, 65, & 32) experienced harm when the facility failed to identify, consistently assess, monitor changes in skin condition, and implement preventative measures and interventions timely, follow Physician Orders (PO) for treatment, and complete weekly documentation of PU progress to promote healing and prevent new or avoidable PUs from developing or existing PU from worsening. These failed practices placed additional residents at risk for worsening of skin integrity, potential for developing PUs, and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care for 2 of 2 (Residents 24 & 37) residents reviewed for Tube Feeding (TF) management including: (1) timely action re: Resident Dietician (RD) recommendation to change the type of TF formula, (2) the administration TF rate consistent with and that followed the practitioner's orders; (3) the periodic evaluation of the amount of TF being administered for consistency with the practitioner's orders, (4) the maintenance of TF pumps consistent with manufacturer's instructions to ensure proper TF delivery, and (5) the implementation of proper resident positioning during TF administration to prevent the risk of aspiration (inhaling food contents into lungs). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: (1) follow measurement tools and conversion tables when preparing modified consistency diets, (2) routinely monitor food temperature on the steam table during meal service, (3) ensure dietary staff were knowledgeable of food safety practices including the appropriate temperatures of Potentially Hazardous Foods (PHF). These failures placed residents at risk for aspiration (inhaling food contents into lungs), development of lung infections, acquiring food-borne illnesses, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that, unless the facility employed a full-time Registered Dietitian (RD), the Director of Food and Nutrition services (Staff J) met Washington State requirements including the completion of an academic program in nutrition or dietetics (the practical application of the science of diet and nutrition in relation to health and/or diseases) approved by the American Dietetic Association/Dietary Manager Association. This failure compromised residents nutritional status and placed residents at risk for receiving unsafe dietary services from a staff without the required competencies and skills to carry out food and nutrition services management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: Cycle/planned and breakout menus were followed during meal service to residents; residents with specialized diets (Resident 429) were provided with meal options that met their needs; risks and benefits were discussed for residents (Resident 579) who elected to consume meals purchased outside of the facility. These failures placed residents at risk for less than adequate nutritional intake, consuming meal portion sizes and calories other than as planned by a Registered Dietician (RD), dissatisfaction with meals, and unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was procured, stored, prepared and served in accordance with professional standards of safety. Facility failed to ensure: (1) food safety was maintained and temperatures monitored in the resident refrigerator, (2) open foods were dated, (3) kitchen equipment (oven) was in good, working condition, (4) menu ingredients were ordered timely, and (5) ready-to-eat foods were covered during transport as required placed residents at risk for unsafe cooking temperatures, ingesting expired and/or contaminated food, and the development of food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included developing an Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 5 (Resident 9, 27, 5, 64, and 56) of 5 residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABOs.

Inspectors wroteBased on observation, interview, and record review the facility failed to consider and act promptly to address concerns raised by residents at the Resident Council (RC). Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken left residents at risk for unresolved concerns, frustration, and a less-than-homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain a safe, clean, and comfortable environment, free of unpleasant noises, left residents at risk for a less than a homelike environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to initiate and thoroughly investigate the occurrences of events for 5 of 20 (Residents 32, 30, 9, 65, & 58) sampled residents whose facility incident reports were reviewed. The facility failed to investigate and correct reported resident grievances and mental health status, identify the cause of an injury, the development of a new wound, and implement protocols and interventions to prevent reoccurrence of events. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 6 (Residents 9, 55, 66, 27, 53 & 17) of 8 residents reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to complete the comprehensive assessments within the regulatory timeframes for 12 of 12 (Residents 68, 24, 65, 27, 37, 373, 4, 5, 579, 9, 66, & 69) sampled residents, 2 of 2 (Residents 54 & 379) supplemental residents, and 1 of 3 (Resident 372) closed records reviewed for resident assessments and timing. The failure to ensure comprehensive admission and Annual Minimum Data Set (MDS - an assessment tool) assessments were completed timely hindered the care planning process necessary to provide the appropriate resident care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframes for 7 of 10 (Residents 9, 32, 53, 58, 62, 25, & 17) sampled residents and 1 of 3 (Resident 4) closed records reviewed for resident assessments and timing. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess 7 of 20 (Residents 9, 66, 37, 65, 69, 27, & 372) residents reviewed for accurate Minimum Data Set (MDS - an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure: (1) all individuals who completed a portion of the assessment signed and certified to the accuracy of the portion they completed, and (2) the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of Care Area Assessments (CAA's) was knowledgeable of the Minimum Data Set (MDS - an assessment tool) process for 3 of 10 (Residents 65, 37, & 69) residents whose comprehensive MDS assessments were reviewed. These failures placed residents at risk for inappropriate care planning and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed for 6 (Residents 30, 68, 76, 9, 55 & 17) of 9 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were comprehensively developed and implemented for 4 (Residents 30, 9, 65, & 62) of 20 sample residents. Failure to develop and implement comprehensive CPs left residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans (CPs) were maintained, revised and updated as required for 10 (Residents 30, 58, 9, 55, 37, 69, 27, 53, 5, & 17) of 20 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: Ensure Physician's Orders (POs) were followed and clarified for 7 (Residents 32, 5, 42, 68, 9, 53, & 37) of 20 sample residents; ensure medications were given within ordered parameters for 3 (Resident 38, 581, &53) of 20 sample residents; and staff were signing for tasks not completed for 1 (Resident 62) of 20 sample residents. These failures left residents at risk for unmet care needs, inappropriate treatment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 6 (Residents 9, 27, 24, 58, 37, & 62) of 20 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 9), bathing (Residents 27, 24, & 58) oral care (Resident 37), and nail care (Resident 62), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed, monitored, and treated as required for 3 (Residents 373, 68, & 579) of 6 residents reviewed for non-pressure skin and 2 supplemental residents (Residents 30 & 58); failed to ensure fluid monitoring was in place for a for 1 (Resident 372) of 3 discharged residents whose records were reviewed; failed to ensure Blood Glucose (BG) was monitored for 1 supplemental resident (Resident 380); failed to ensure residents with constipation/diarrhea were provided bowel care for 1 (Resident 17) of 4 residents reviewed for constipation/diarrhea. These failures placed residents at risk for new or worsening skin impairment, fluid overload, uncontrolled BG, skin irritation, discomfort, embarrassment, and other negative health outcomes

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 6 (Residents 24, 27, 53, 38, 68, & 62) of 10 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure accurate intakes were documented, identify and act on significant weight changes placed residents at risk for delayed identification of interventions for continued weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure 5 (Residents 30, 55, 49, 53 & 5) of 5 residents whose medication regimens were reviewed, were free of unnecessary psychotropic medications. This failure left residents at risk for unnecessary medications, adverse side effects and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 4 of 26 medications for 3 of 8 residents (Resident 66, 42, & 581) observed during medication pass resulted in a medication error rate of 15.38%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance, palatable, and served at the proper temperature. Observation of meal preparation and interviews with 5 (Residents 27, 53, 25, 68, & 38) sample residents and 1 supplemental (Resident 40) resident identified concerns about the taste, temperature, and overall palatability of food served by the facility. Failure by the facility to ensure meals were at the proper temperature and palatable when served, placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals.

Inspectors wrote<Ice Cart Service> Observations on 09/20/2023 at 3:42 PM showed Staff FF (Licensed Practical Nurse) obtain a resident's water pitcher from room [ROOM NUMBER]. Staff FF set the water pitcher down on the ice cart, used a scoop to get ice out of the bin, and then touched the scoop on the inside of the resident's water pitcher while filling it with ice. Staff FF then delivered that water pitcher to room [ROOM NUMBER] and went into room [ROOM NUMBER] to pick up another resident's water pitcher. Staff FF placed the next water pitcher down on the ice cart, picked up the contaminated scoop, put it into the main bin to get more ice, and again touched the scoop inside of the resident's water pitcher. Observations on 09/25/2023 at 12:14 PM showed the ice cart in the hallway with no ice scoop in the clear container in the front. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that promoted resident respect and dignity for 4 (Residents 25, 429, 580, & 14) of 4 Residents reviewed for dignity concerns. Facility staff failed to obtain consent prior to sorting through and organizing Resident 25's personal belongings, treat Resident 429 in a dignified manner, provide silverware that was consistent with a homelike environment for Resident 580, and provide adaptive utensils for Resident 14. These failures placed residents at risk for feelings of diminished and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to inform residents in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 Residents (Residents 30 & 5) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' ability to exercise their right to make an informed decision about proposed treatments and prevented the residents from exercising their right to decline the treatments/therapies.

Inspectors wroteBased on interview and record review the facility failed to allow 2 (Residents 62 & 27) of 20 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the appropriate Advance Directive (AD) in place for 4 of 20 (Residents 65, 5, 373, & 24) reviewed for ADs. The facility failed to help residents (Resident 65) formulate an AD and document in the medical records that assistance was offered. The facility failed to obtain a copy from residents (Resident 5, 373, & 24) with an existing AD and make the documentation readily available in the medical records and accessible to facility staff. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on interview and record review the facility failed to log/report an allegation of neglect for 1 (Resident 32) of 20 sample residents reviewed. This failure placed residents at risk for unidentified neglect, avoidable pain, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 4 (Residents 9, 55, 66, & 17) of 8 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized .

Inspectors wroteBased on interview and record review the facility failed for 3 (Residents 68, 9, & 66) of 8 newly admitted and readmitted residents reviewed, to provide residents and/or their representative with a summary of their baseline Care Plan (CP). This failure resulted in residents and/or families not being informed of their initial plan for delivery of care and services, and placed residents at risk for unmet needs, and possible complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement individualized activity plans and ensure activity programs met the needs of each resident for 2 of 3 residents (Residents 38 & 58) reviewed for activities, and 1 supplemental resident (Resident 62). Failure to consistently implement meaningful individual activity plans left residents at risk for boredom, frustration, isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were assessed and received necessary treatment and assistive devices to maintain vision abilities for 2 of 4 (Residents 65 & 62) residents reviewed for vision. Failure to identify vision deficits and to ensure residents received assistance with the use of corrective lenses left residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: Ensure 2 of 2 (Residents 30 & 9) residents with Suicidal Ideation (SI) were investigated for root cause, or provided an environment free from items they were not assessed to be safe with; ensure fall mats were used appropriately for 2 of 4 (Residents 58 & 5) reviewed for falls. These failures left residents at risk for falls, injury, self-harm, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents admitted with Foley Catheters (F/C - a flexible tube inserted into the bladder) were assessed for the continued need for a F/C, attempted to remove the F/C as soon as possible, F/C tubing was secured with a leg strap to prevent accidental tugging and pulling, and a privacy bag (to cover the F/C bag) in place for 1 (Resident 66) of 3 residents reviewed for the F/C. These failures placed residents at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 1 of 2 (Resident 69) residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure drugs and biologicals were secured for 5 (Resident 54, 62, 66, 27, & 25) of 24 residents observed with medication in their rooms. The facility failed to ensure proper storage of drugs and biologicals on 2 (Medicare 2 and 2 South Hall Cart) of 4 medication carts. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed, self-administration of medications by residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory (lab-blood test) tests were completed as ordered for 2 of 5 (Residents 49 & 5) sample residents whose drug regimens were reviewed, and 3 (Residents 58, 62, & 68) supplemental residents. This failure placed residents at risk of medical complications from lack of monitoring of chronic medical conditions, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete, accurate, and readily accessible for 4 (Resident 49, 38, 68, & 9) of 20 sample residents whose records were reviewed. The facility failed to ensure Medication Administration Records (MAR), Treatment Administration Records (TAR), weight records, and meal consumption documentation was complete and accurately reflected the care provided. These failures placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to administer a pneumococcal (pneumonia) vaccination within the recommended timeframe for 2 (Residents 5 and 49) of 5 residents reviewed for vaccinations. This failure placed residents at risk for contracting pneumonia, with its associated complications.

Inspectors wroteBased on interview and record review the facility failed to ensure any of the 97 staff were offered Covid-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing and could result in impairment or death) education on the benefits and potential risk associated with the Covid-19 vaccine. This failure placed staff at risk for not being able to make an informed decision about immunizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident Wheelchairs (WCs) were maintain in good, safe, working order for 3 (Residents 30, 579 & 38) of 20 sampled residents reviewed. Failure to ensure WCs were in maintained in safe working condition left residents at risk for accidents, frustration, and other negative health outcomes.